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Unlike the generators of respiratory rhythm, the entire re ex apparatus for swallowing may be located in the NTS There is, however, no direct connection between the NTS and the cranial nerve motor nuclei Therefore it is presumed that control must be exerted through premotor neurons located in adjacent reticular brainstem regions There have been few comparable anatomic studies of the structures responsible for swallowing in humans As to the cortical regions that are involved in swallowing, it appears from PET studies that the inferior precentral gyrus and the posterior inferior frontal gyrus are activated, and lesions in these parts of the brain give rise to the most profound cases of dysphagia Dysphagia and Aspiration Weakness or incoordination of the swallowing apparatus is manifest as dysphagia and, at times, aspiration The patient himself is often able to discriminate one of several types of defect: (1) dif culty initiating swallowing, which leaves solids stuck in the oropharynx; (2) nasal regurgitation of liquids; (3) frequent coughing and choking immediately after swallowing and a hoarse, wet cough following the ingestion of uids; or (4) some combination of these Extrapyramidal diseases, notably Parkinson disease, reduce the frequency of swallowing and cause an incoordination of breathing and swallowing, as noted below It is surprising how often the tongue and the muscles that cause palatal elevation appear on direct examination to act normally despite an obvious failure of coordinated swallowing In this regard, the use of the gag re ex as a neurologic sign is quite limited, being most helpful when there is a medullary lesion or the lower cranial nerves are affected In our experience, palatal elevation in response to touching the posterior pharynx only demonstrates that cranial nerves IX and X and the local musculature are not entirely dysfunctional; however, the presence of the re ex does not assure the smooth coordination of the swallowing mechanism and, more importantly, does not obviate the risk of aspiration It should also be emphasized that dif culties with swallowing may begin subtly and express themselves as weight loss or as a noticeable increase in the time required to swallow and to eat a meal Nodding or sideways head movements to assist the propulsion of the bolus, or the need to repeatedly wash food down with water, are other clues to the presence of dysphagia Sometimes recurrent minor pneumonias are the only manifestation of intermittent ( silent ) aspiration A defect in the initiation of swallowing is usually attributable to weakness of the tongue and may be a manifestation of myasthenia gravis, motor neuron disease, or, rarely, in ammatory disease of the muscle; it may be due to palsies of the 12th cranial nerve (metastases at the base of the skull or meningoradiculitis, carotid dissection), and to a number of other causes In all these cases there is usually an associated dysarthria with dif culty pronouncing lingual sounds The second type of dysphagia, associated with nasal regurgitation of liquids, indicates a failure of velopalatine closure and is characteristic of myasthenia gravis, 10th nerve palsy of any cause, or incoordination of swallowing due to bulbar or pseudobulbar palsy A nasal pattern of speech with air escaping from the nose is a usual accompaniment Viewed from a physiologic perspective, the causes of aspiration fall into four main categories: (1) weakness of the pharyngeal musculature due to lesions of the vagus on one or both sides; (2) a myopathy (myotonic and oculopharyngeal dystrophies) or neuromuscular disease (amyotrophic lateral sclerosis and myasthenia gravis); (3) a medullary lesion that affects the NTS or the cranial motor nuclei (lateral medullary infarction is the prototype) but.

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syringomyelia-syringobulbia and rarely multiple sclerosis, polio, and brainstem tumors may have the same effects; or (4) a less well de ned mechanism of slowed or discoordinated swallowing arising from corticospinal disease (pseudobulbar palsy, hemispheral stroke) or from diseases of the basal ganglia (mainly Parkinson disease) that alter the timing of breathing and swallowing and permit the airway to remain open as food passes through the posterior pharynx In the latter cases a decreased frequency of swallowing also causes saliva to pool in the mouth (leading to drooling) and adds to the risk of aspiration Although the case has been made above that swallowing is a brainstem re ex, aspiration and swallowing dif culty after severe stroke occur in a surprisingly large number of cases of cerebral infarction and hemiparesis without brainstem damage The problem is most evident during the rst few days after a hemispheral stroke on either side of the brain (Meadows) These effects last for weeks and render the patient subject to pneumonia and fever In the clinical and uoroscopic study by Mann and colleagues, half of patients still had manifest abnormalities of swallowing 6 months after their strokes Some insight into the nature of swallowing dysfunction after stroke is provided by Hamdy and colleagues, who correlated the presence of dysphagia with a lesser degree of motor representation of pharyngeal muscles in the unaffected hemisphere, as assessed by magnetic stimulation of the cortex

Pain on swallowing occurs under a different set of circumstances, the one of most neurologic interest being glossopharyngeal neuralgia (pages 163 and 1185) Video uoroscopy has become a useful tool in determining the presence of aspiration during swallowing and in differentiating the several types of dysphagia The movement of the bolus by the tongue, the timing of re ex swallowing, and the closure of the pharyngeal and palatal openings are judged directly by observation of a bolus of food mixed with barium or of liquid barium alone However, authorities in the eld, such as Wiles, whose reviews are recommended (see also Hughes and Wiles), warn that unquali ed dependence on video uoroscopy is unwise They remark that observation of the patient swallowing water and repeated observation of the patient while eating can be equally informative Having the patient swallow water is a particularly effective test of laryngeal closure; the presence of coughing, wet hoarseness or breathlessness, and/or the need to swallow small volumes slowly are indicative of a high risk of aspiration Based on bedside observations and on video uoroscopy studies, an experienced therapist can make recommendations regarding the safety of oral feeding, changes in the consistency and texture of the diet, postural adjustments, and the need to insert a tracheostomy or feeding tube

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